Download 1 Management of Acute Kidney Injury Type: Policy Register No

Management of Acute Kidney Injury
Type: Policy
Register No: 13007
Status:
Public
Developed in response to:
Contributes to: CQC Outcome
Local need
NCEPOD on AKI
4
Consulted With
Dr Abeygunasekara
Post/Committee/Group
Consultant Nephrologist
Date
17/1/2013
Dr Aung Lwin
ITU and Acute Medical
Consultant
ITU Consultant
Dr Kevin Kiff, ITU Consultant
12/3/2012
Dr Jake Collins
Professionally Approved By
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management Group
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in
conjunction with)
Document Review History
Version No
1.0
1.1 Extended for 6 mths
agreed by DRAG Chair
12/3/2013
12/3/2013
1.1
Emergency Care
Document Ratification Group
28th March 2013
April 2013
15th April 2013
December 2016
Dr Anthony Chan, Consultant Nephrologist
Medical and Nursing Staff
Intranet & Website
10080 Adult Patients Observation Policy
Authored/Reviewed by
Active Date
Dr Anthony Chan, Consultant Nephrologist
Dr Anthony Chan, Consultant Nephrologist
15 April 2013
14th June 2016
1
INDEX
1.0
Purpose of guideline
2.0
Background
3.0
Scope
4.0
Definition of Acute Kidney Injury
5.0
Staging of Acute Kidney Injury
6.0
Diagnosis and risk assessment of Acute Kidney Injury
7.0
Investigations for Acute Kidney Injury
8.0
Management of Acute Kidney Injury
9.0
Referral to specialist services for Acute Kidney Injury
10.0
Training
11.0
Implementation and Communication
12.0
Breaches
13.0
Audit and monitoring
14.0
References
Appendix 1 Algorithm for the Preliminary Management of Acute Kidney Injury
2
1.0
Purpose of Guideline
1.1
This guideline is intended to provide guidance on the preliminary management of
acute kidney injury in non-specialist areas such as accident & emergency, acute
admission units and general wards.
2.0
Background
2.1
AKI (Acute Kidney Injury) is common in hospitalised patients and is associated with
poor prognosis and high mortality. Patients presenting with uncomplicated AKI have
a mortality rate of up to 10%. In contrast, patients with AKI and multi-organ failure
are reported to have mortality rates of over 50% and rises further to as high as 80% if
renal replacement therapy is required.
2.2
The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
Adding Insult to Injury Acute Kidney Injury Report 2009, examined the care of patients
who died with a diagnosis of AKI. The report identified many deficiencies in the care of
patients with AKI and only 50% of patients received what it considers ‘good care’. There
was poor attention to detail, inadequate assessment of risk factors for AKI and an
unacceptable delay in recognising post admission AKI.
2.3
The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
AKI report recommends:
•
•
•
•
•
•
•
all emergency admissions should have a risk assessment for AKI
all emergency admissions should have electrolytes checked on admission and
appropriately thereafter
predictable avoidable AKI should not occur
all acute admission should receive adequate senior reviews (consultant review within
12 hours)
there should be sufficient critical care and renal beds to allow rapid step up care
undergraduate medical training should include the recognition of the acutely ill patient
and the prevention, diagnosis and management of AKI
postgraduate training in all specialties should include training in the detection,
prevention and management of AKI.
3.0
Scope
3.1
This guideline applies to the management of acute kidney injury in adult patients only.
3.2
The management of esoteric causes of AKI is not covered in this guideline.
3.3
Hyperkalemia in acute kidney injury is not covered in this guideline.
3.4
It is inappropriate to refer AKI patients with more than single-organ dysfunction, to
the Renal Service when it is anticipated that they will require more than renal
replacement therapy. For example the septic, hypotensive and respiratory compromised
patient with AKI will require critical care referral (ITU) instead of the renal services.
4.0
Definition of Acute Kidney Injury
4.1
Acute kidney injury is defined when one of the following criteria is met
• Serum creatinine rises by ≥ 26µmol/L within 48 hours or
3
•
•
•
Serum creatinine rises ≥ 1.5 fold from the reference value, which is known or
presumed to have occurred within one week or
urine output is < 0.5ml/kg/hr for >6 consecutive hours
4.2
The reference serum creatinine should be the lowest creatinine value recorded within
3 months of the event.
4.3
If a reference serum creatinine value is not available within 3 months and AKI is
suspected
•
repeat serum creatinine within 24 hours
•
a reference serum creatinine value can be estimated from the nadir serum creatinine
value if patient recovers from AKI
5.0
Staging of Acute Kidney Injury
Stage
Serum creatinine (SCr) criteria
Urine output criteria
1
increase ≥ 26 μmol/L within 48hrs or
<0.5 mL/kg/hr for>6 consecutive
hrs
increase ≥1.5 to 1.9 X reference SCr
2
increase ≥ 2 to 2.9 X reference SCr
<0.5 mL/kg/ hr for > 12 hrs
3
increase ≥3 X reference SCr or
<0.3 mL/kg/ hr for > 24 hrs or
anuria for 12 hrs
increase ≥354 μmol/L or
commenced on renal replacement therapy (RRT)
irrespective of stage
6.0
Diagnosis and risk assessment of Acute Kidney Injury
6.1
Clinical assessment of the patient with AKI should include comprehensive history
and physical examination.
6.2
The history taking should include the following:
•
Review of patient notes
•
AKI risk factors:
•
age > 75 yrs
•
chronic kidney disease (CKD,eGFR< 60 mls/min/1.73m2)
•
Cardiac failure
•
Atherosclerotic peripheral vascular disease
•
Liver disease
•
Diabetes mellitus
4
•
Review of medications
•
Look for potential causes for AKI including
•
•
reduced fluid intake
•
increased fluid losses
•
urinary tract symptoms
•
recent drug ingestion
•
sepsis
Systemic clinical features suggestive of vasculitides
•
•
•
6.3
fever
rash
joint pains
Clinical examination must include:
•
•
General
•
rash
•
uveitis
•
joint swelling
Assessment of volume status
•
core temperature
•
peripheral perfusion
•
heart rate
•
blood pressure
•
jugular venous pressure
•
signs of renovascular disease
•
audible bruits
•
impalpable peripheral pulses
•
abdominal examination
•
palpable bladder
7.0
Investigations for Acute Kidney Injury
7.1
All patients presenting with AKI should have appropriate baseline investigations
performed which should include a urinalysis and a renal tract ultrasound within 24
hours.
7.2
Baseline set of laboratory investigations should be sent including:
•
Urea and electrolytes
•
FBC and clotting profile
•
urinalysis (± microscopy)
5
•
7.3
microbiology

urine culture (if infection is suspected)

blood culture (if infection is suspected)
Specific renal investigations are requested dependent upon the clinical presentation
and may include:
•
renal immunology (ANA, DNA, ANCA, complements, electrophoresis)
•
urinary biochemistry

electrolytes

osmolality
•
ECG
•
chest x-ray
•
abdominal x-ray
•
renal tract ultrasound (ideally within 24hrs if obstruction suspected or esoteric cause
suspected requiring a kidney biopsy)
•
kidney biopsy
8.0
Management of a patient with Acute Kidney Injury
8.1
If the advice is this guideline is followed, the care of patients with AKI can often be
undertaken in the non-specialist areas such as acute admission units and general
wards.
8.2
The management of AKI in the majority of cases is supportive with treatment of the
underlying cause/s. General supportive measures include optimisation of
haemodynamic status by appropriate fluid therapy, and treatment of any underlying
sepsis. Nephrotoxic medications should be stopped.
8.3
Consider insertion of a central venous pressure (CVP) line and urinary catheter (not
mandatory and could introduce infection) to aid with assessment of volume status.
8.4
Resuscitation with intravenous (IV) fluids:
•
•
•
Begin with fluid bolus of 500mL (250mL if there is history of cardiac failure or over
age 75 years) of crystalloid (sodium chloride 0.9% if hyperkalaemic).
Assess for clinical response in terms of:
 peripheral perfusion
 pulse (reduction in pulse if tachycardic)
 rise in jugular venous pressure (JVP)
 blood pressure (BP) rise
 pulmonary oedema (presence obviates further fluid)
 urine output (increasing if oliguric)
If there is no clinical response and no pulmonary oedema, administer a further 500mL
of crystalloid (250mL if cardiac failure or over age 75 years), and reassess clinically.
Discuss case with senior member of team
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8.5
•
If clinical response to fluid bolus is achieved, continue with intravenous fluids until
euvolaemia is restored or until independent oral intake is achieved and ongoing fluid
losses resolves
•
If patient remains oliguric (less than 0.3mL per kg per 24 hours) despite adequate
volume resuscitation, consider the patient as having volume unresponsive AKI and
refer to critical care or renal service as appropriate
Review of patient’s medication is mandatory as many cases of AKI are medication
related. The following medications should be withheld or given in the presence of AKI
or in patients who are at risk of AKI:
•
•
•
•
8.6
Monitoring of the patient with AKI is an essential part of patient management. A polyuric
phase may develop during the recovery of AKI. Patients are at increased risk of
developing negative fluid balance and electrolyte disturbances. The following are
required for monitoring patients with AKI:
•
•
•
•
8.7
Angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers
(ARB)
Diuretics
Non-steroidal anti-inflammatory drugs
Aminoglycoside antibiotics – please discuss alternative antibiotics with microbiologist
in patients with AKI or in patients with chronic kidney disease stage 3 and above.
Regular physiological surveillance (PAR score), frequency depending on clinical
severity
Fluid balance chart recording all input and output, maintain a positive balance of
500ml
Daily weight
Daily renal profile and full blood count
Post recovery of AKI and post-discharge advice:
•
•
Advise GP to recheck renal function 1 month after recovery of AKI
Advice on the judicious and cautious re-instatement of anti-hypertensive medication
and ACEI/ARB/diuretics to patient’s GP, with careful monitoring of renal function. This
will prevent rebound admissions due to uncontrolled hypertension, and congestive
heart failure.
9.0
Referral to specialist services for Acute Kidney Injury
9.1
Not all patients with AKI require specialist input. This is especially the case in prerenal AKI which often responds rapidly to fluid resuscitation, discontinuation of
nephrotoxic medication and treatment of underlying sepsis.
9.2
However, when a patient with worsening AKI requires escalation of care, referral to
specialist areas such as critical care (ITU, MHDU) or renal service (Terling Ward) will
depend on the clinical condition of the patient as reflected by their physiological scores
(PAR scores).
9.3
It is inappropriate to refer to the renal service the AKI patient with more than singleorgan dysfunction where it is anticipated that they will require more than renal
7
replacement therapy. For example the septic, hypotensive and respiratory compromised
patient with AKI will require critical care referral (ITU) instead of the renal services.
9.4
Specialist renal input is recommended in the following circumstances:
•
•
•
•
•
9.5
Renal referral procedure
•
•
•
•
•
9.6
Oliguria and non-response to fluid replacement
Stage 3 AKI
AKI with intractable hyperkalemia, metabolic acidosis and volume overload where
renal replacement therapy is imminently required
Suspected esoteric causes of AKI such as vasculitis where urgent pre-sumptive
treatment will need to be commenced
Non-resolving AKI
Referral is addressed to the renal consultant on call of the week
Contact Switchboard for renal consultant on call rota
Fax referrals to 4426
Do not fax to the Renal Dialysis Unit
Bleep renal registrar to inform of the referral, or contact renal consultant on call if
registrar not available.
Residual chronic kidney disease post-AKI
9.6.1 A significant proportion of patients may have chronic kidney disease that may require
long term care and management. Arrangements for outpatient renal clinic follow up
should be made prior to patient discharge. This can be done by requesting for
outpatient follow up appointment (with a named renal consultant) in the discharge
letter on Extramed.
10.0
Training
10.1
Training on the subject of AKI will included in formal junior doctor training programmes
as per Mandatory Training Policy (Training Needs Analysis)
11.0
Implementation and Communication
11.1
Once ratified, it is the responsibility of Corporate Services to ensure that the guideline is
uploaded to the intranet and website and notified to all staff via Focus.
11.2
The policy will be sent to all Clinical Directors and Corporate Nursing for information and
dissemination amongst their teams by the author.
11.3
The guideline will be introduced to junior doctors during their induction programmes.
11.4
The author will be responsible for ensuring that all post ratification communications
that are required take place.
12.0
Breaches
12.1
A risk event form should be completed for any instance of non-compliance with this
guideline.
8
13.0
Audit and monitoring
An annual audit will be carried out to assess compliance with this guideline. This will be
done on all patients with severe AKI requiring haemodialysis support. Case notes review
will be done on these patients to assess compliance with this guideline. Findings will be
presented at Trust audit meetings.
14.0 References
1. Renal Association Acute Kidney Injury Guidelines 2011.
http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx
2. Clinical guideline on Severe Sepsis 2008. MEHT intranet
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Appendix 1
Algorithm for the Preliminary Management of Acute Kidney Injury
Suspected
AKI (3.1)
No
Continue to
monitor for risk
of AKI (4.2)
Yes
•
δSCr ≥ 26µmol/L within 48 hours or
•
δSCr ≥ 1.5 x from a known baseline
•
presumed to have occurred within one week or
•
UO < 0.5ml/kg/hr for >6 consecutive hours
Hypovolaemia
Sepsis
Cardiac Insufficiency
Staging of AKI (3.2)
Correct Hypovolaemia
Treat Sepsis
Restore cardiac output
ACEI,ARB, NSAIDS & Diuretics
History,
Physical
Examination
and Lab
Tests (4-5)
Symptoms + signs of vasculitides
Active urine – blood, protein &
casts
Hypercalcaemia, bony pains
Antibiotics, NSAIDs and other
meds
MAHA, thrombocytopenia
Anuria
History of renal stones, colic
Lower urinary tract symptoms
Palpable bladder
Urgent renal referral (8)
Haemdodynamically stable AKI stage 3 (refer ITU if unstable)
Oligoanuria despite resuscitation, and pulmonary oedema
Medication review
Stop Nephrotoxics
Intrinsic AKI suspected
Urgent vasculitic screen
and renal referral
Urgent USS
Urgent decompression if
obstructed
Treat causes of AKI
Monitor for complications
Intractable hyperkalemia,, uraemic encephalopathy and
acidosis
Post-discharge care
Evidence of vasculitides
10